Activity Transcript

Rhonda Acholonu, MD, FAAP: My name is Dr Rhonda Acholonu. I am the Vice Chair for Education and the Associate Professor of Pediatrics at the Children's Hospital at Montefiore. We are very excited to present to you "Social Determinants of Health: How to Take Action."

I would like to introduce my panelists. First, Dr Kevin Fiori.

Kevin Fiori, MD, MPH, MSc: Hi, I'm Kevin Fiori. I'm a general pediatrician. I'm an Assistant Professor in the Departments of Pediatrics and Family and Social Medicine at the Albert Einstein College of Medicine and the Director of Social Determinants of Health for Montefiore Health System.

Dr Acholonu: Next, Dr Paula Braveman.

Paula Braveman, MD, MPH: Hello, I'm Paula Braveman. I'm a Professor of Family and Community Medicine and the Founding Director of the Center for Health Equity at the University of California, San Francisco.

Dr Acholonu: Thank you to our panelists.

Dr Braveman, I'd like to start with you to start us on this journey of talking about the role of social factors on health and health equity.

Dr Braveman: It's a pleasure to participate in this round table. The theme of this Medscape initiative is elevating health equity, and this webinar focuses on the actions needed to advance health equity by addressing the social determinants of health. I'm hoping to set the stage for the session by defining what health equity is and summarizing the evidence base that shows that actions for health equity need to occur not only in the clinical setting, but also where people live, work, learn, and play.

There are many different definitions of health equity, each with different strength and weaknesses. This definition is one I developed with colleagues at the Robert Wood Johnson Foundation in an attempt to overcome some of the weaknesses of prior definitions, although this one too, of course, has its limitations. For one thing, it's long, so we sometimes use just the first sentence. Health equity means that everyone has a fair and just opportunity to be as healthy as possible.

But that could be interpreted very differently by different people. So the rest of the definition is designed to reduce the ambiguity by noting that achieving health equity requires removing obstacles to health, such as poverty, discrimination, which includes racism and other forms of discrimination, powerlessness, and their consequences, including lack of access to good jobs with fair pay, safe environments and quality education, housing, and healthcare. That part of the definition is intended to illustrate and restrict what it would mean to ensure that everyone has fair and just opportunities to be as healthy as possible.

The final part aims to further reduce the ambiguity by stating that to know whether or not we're moving toward greater health equity, we must measure the magnitude of disparities in health and its determinants that adversely affect excluded or marginalized groups. Without measurement, there's no accountability.

This is a picture that I really like because it conveys the notion that some people, let's say because of being born into a poor family or because of racism, face more obstacles to being healthy. And society's challenge, and according to human rights principles, its obligation, is to remove the obstacles.

So in a nutshell, I think there are 3 essential but overlapping elements of health equity. The first, social justice; the second, removing obstacles to health for disenfranchised, marginalized and excluded groups; and third, addressing all determinants of health, not only healthcare.

And now I want to focus on the evidence base for the need to address factors beyond healthcare. It is massive. Over the past 3 decades, a substantial body of very credible scientific knowledge has accumulated that links all of the factors that are listed here with health. Although certainly there is much that is unknown, in most cases there is considerable understanding of pathways and biological mechanisms that are involved.

By wealth, I mean accumulated financial assets like a home and savings. Both income and wealth can shape one's access to medical care, the affordability of a nutritious diet and exercise opportunities, whether you have to raise your kids in a house full of mold and dust mites, and whether you can live in a safe, unpolluted neighborhood that has good services. All of these can affect stress, which can jeopardize family stability, which then adds more stress.

We know that concentrated poverty creates unhealthy places. One of the most health-damaging aspects of a poor neighborhood is that children's education is often shortchanged because school are poorly resourced because in this country we do not have equal school funding per pupil. School funding depends very heavily on local property taxes, so poor communities are at a disadvantage. Furthermore, longstanding biased lending practices have systematically cut many people of color off from home ownership, so their communities have particularly little property tax revenue.

We don't have time to go through this diagram, but I'm showing it to you because I want to give you a glimpse of the complexity of the pathways that we usually are dealing with when studying how social factors influence health. The causal pathways tend to be long and complex and they play out across decades or lifetimes. This diagram shows that the literature indicates that education, referring to level of schooling, can affect health through 3 major pathways: the first, health knowledge and coping skills. The second, because our education generally determines the kind of work that we can get and the income and the benefits that go with it. And third, psychosocial pathways, for example, our controlled beliefs.

Over the past 20 to 25 years, neuroscientists have identified that chronic stress, even at a relatively undramatic level, appears more toxic for health than acute stress. Both chronic poverty and racism are stressful. The biological mechanisms include neuroendocrine processes leading to inflammation and immune system dysfunction, which in turn can lead to chronic disease in adulthood.

Racism takes many forms. Structural or systemic racism is the racism that you don't see unless you're the victim. The racism that is deeply embedded in systems, laws, policies, and entrenched practices. It systematically puts people of color at a disadvantage, whether or not any individual is intending to discriminate at any particular moment in time.

Structural racism tracks people of color into economic disadvantage through residential segregation, poorly resourced schools, biased lending, and biased policing and sentencing. It also damages health by exposing people of color to harmful conditions, for example, through environmental injustice and mass incarceration. The form of racism that most people tend to think of is different. It's what is called interpersonal racism. That is the incidents that happen between individuals.

All of the forms of racism are tremendous sources of stress. The health effects of structural racism are indirect. For example, through putting someone at economic disadvantage, whereas the health effects of interpersonal racism are direct and it's not just overt interpersonal incidents that cause stress. Studies have linked constant vigilance or chronic worry about whether one will be treated unfairly because of race with the physiologic effects of stress, notably inflammation and immune dysfunction with consequent increased risk of chronic disease.

There are so many scientific advances in the last 2 decades that have revealed how social factors influence health. Elucidating the physiologic effects of chronic stress is one of the most important as is knowledge of epigenetic effects and of the importance of early childhood experiences.

The science that tells us that social factors have tremendous effects on health also tells us that if we want to achieve health equity, a fair and just opportunity for everyone to be as healthy as possible, those social factors must be addressed. I know that's not what we physicians and other clinicians have been trained to do, but in the next parts of this session, Dr Acholonu and Dr Fiori will be discussing some very promising models of how clinicians and medical institutions even now are helping to tear down the obstacles that prevent so many people from being healthy. Thank you.

Dr Acholonu: Thank you so much, Dr Braveman, for that fabulous introduction into social determinants of health and why it matters, and also for the longstanding research on this topic. It's incredibly impressive.

I'd like to turn this over to my colleague, Dr Fiori, who will present some of the research that he and his colleagues have been doing to build up the evidence for the impact of social needs on health. Dr Fiori.

Dr Fiori: Thank you so much. One thing that we've started to do here at Montefiore Health System, which is based in New York City in the borough of the Bronx, is we've started screening for social needs as standard of care. Dr Acholonu and I, we'll talk a little bit more about that in some coming slides. But one thing I want to focus on right now is what some of that data has revealed to us.

This is a study that we conducted that was published in the American Journal of Public Health in 2020. It was looking at 41,000 of our patients here in the Bronx. What we wanted just to look at was for those patients, how many missed appointments they had and comparing patients that had endorsed social needs on a standardized social needs screener that we use vs those that had not endorsed any social needs.

What we found was there was approximately a 5% difference between those that endorsed social needs and those that did not as it pertained to missed appointments. Now, that difference of 5% translates into approximately 176,000 no-show appointments with an estimated loss of revenue of over $18 million. So in addition to the missed opportunity to provide really excellent care to these patients, it also has financial implications on health systems.

We've also looked at the association between certain clinical diagnoses and the endorsement of social needs. This is a study that looked at 29,000 adult patients in our health system. What we were trying to understand was these associations between key clinical and behavioral health risk factors and social needs. And as you can see by the figures on this slide, what we see is associations between both certain behavioral risk factors and clinical diagnoses and specific social needs. For example, patients that endorse having an alcohol or drug abuse problem were more likely to report having problems with healthcare transportation as compared to patients that did not.

We've also focused on specific clinical diagnoses like diabetes. For this study, we looked at 5000 adults and their controls, and we designated a control as having a hemoglobin A1C less than 9. And so what we wanted to understand was whether there was a difference in control status based on whether patients also endorsed social needs. What we did see is an elevated risk of being not in control in terms of diabetes and endorsing social needs.

And so it's these kinds of data that is helping our health system understand how social needs is impacting clinical care and helping us to target and design interventions that can help families mitigate some of the challenges and barriers that unmet social needs create in our mission to provide excellent care at our health system.

Dr Acholonu: Thank you, Dr Fiori. This is really compelling evidence for why it's so important to screen for social needs. Can you talk a little bit about how you actually do this? How is this done in the clinic, and do you use any of these social assessment tools?

Dr Fiori: Yes, it's a great question. I feel very proud as a pediatrician that our professional academy came out in 2016 with a policy statement that actually recommended that we screen for social needs as part of routine care. I think this, as Dr Braveman was mentioning, cumulated after a body of evidence that has been produced, especially in the past 10 years, about the relationship that screening for social needs in clinical practice leads to increases in social service uptake and has been associated with improved health outcomes.

We at Montefiore have looked and used as a framework, this National Academy of Sciences report that came out in 2019 integrating social care to the delivery of healthcare, thinking about the kinds of activities that we can do as a health system to make meaningful difference in this area. And for the purposes of this roundtable, we're going to focus just on activities related to awareness. So this idea of identifying social risks and assets of patients that we care for, and this idea of assistance, so activities that we can do to actually reduce that social risk by providing direct assistance, whether through social service navigation or providing services directly in our clinic.

The other thing I want to point out is that based at Dr Braveman's institution, there is the Social Intervention Research and Intervention Network. This is a really valuable network which puts out a lot of resources that are useful to health systems, including a systematic review of social needs screening tools. So health systems can look at what's available, look at the different types of tools that are out there that could be used at their health system in their context, and decide what might be most appropriate and feasible based on their context and what their clinical teams would like to accomplish.

Dr Acholonu: It sounds like that network is incredibly helpful for our audience in terms of thinking about what kind of tools might be available. Can you, as somebody at a health system that has implemented this, talk a little bit in more detail about your system, our system, and what we've implemented and actually how it really works in practice?

Dr Fiori: Sure. Montefiore as an institution actually has a long history of focusing on social determinants of health. We have a training program that started in the 1970s that focuses on social medicine. So this for us was a just more recent iteration of what we've tried to do in terms of integrating social care into healthcare delivery. So starting in 2017, we embarked on a journey of integrating a standardized tool that would be available for our clinical teams to screen for unmet social needs during clinical care.

We adapted a screening tool from an organization called Health Leads who puts out a really fantastic social needs screening tool kit. We took that adapted screen, which was developed with a multidisciplinary committee of social workers, clinicians, key health system leaders in administration, and some of our community-based partners. We took that screen, we piloted it. We then put it into our electronic health record so that it would be available and something that we could track for other clinical teams.

We worked with some of our partners in developing referral workflows so that when we identified patients with unmet social needs, we could refer them to a team of community health workers that were working closely with some of our federally qualified health centers. We also invested in an online social service directory resource that gave our clinical teams access to up-to-date information about existing community assets surrounding their clinics within the Bronx so that if a family, for example, identified food insecurity as a need, the clinical team could quickly search on this social service directory for an up-to-date list of resources around where the patient lived. And so this is something that we embarked on in 2017.

Just to show you a little bit more details about the mechanism of how we introduced the standardized screen into our electronic health record, we actually have 2 routes by which patients can complete the screen. One route includes the patients being provided the screen when they arrive for their visit. They fill it out and then it is entered into our electronic health record as part of the triage process. Another route includes patients through something called MyChart, which is an online communication portal with our electronic health record. They can complete the screener online and then the screening results automatically get routed into our electronic health record.

And so then we've set up, in working with our colleagues in IT, a way for the clinical team to quickly see the results of the screening at the last screen, which is shown on what we call the social determinants of health wheel. So a provider or somebody on the clinical team can quickly look at this wheel, which is on sort of a summary page of their electronic health record. They can scroll over each one of these categories and they can see what the patient responded to in terms of the questions, and also when was the last time that they were screened. So it's a quick way to share this information across clinical teams when you have families or patients that may be interacting with different parts of the health system so that everyone can be on the same page about what the patient's needs are.

We've also invested in documentation and workflows on when we identify patients with unmet social needs, referring them if the patient requests it to our team of community health workers who are Bronx community members. They have expertise in social service navigation and they work with our families in an intensive follow-up way to help them navigate the assets that exist within the community here in the Bronx.

We also have a way for these team members to document how they help the family within the electronic health record so that information can get fed back to the clinical team or that patient's primary care provider and there's a closed loop communication on how we're all working with the patients.

Dr Acholonu: This is great. This is a great way for people to see and understand how to actually implement this screening. What have some of your results been and what has your experience been as you have incorporated social determinants of health screening at Montefiore?

Dr Fiori: It's a great question. We provided all of the clinical teams, and I'm talking about we started in our primary care network, which includes 18 primary care practices spread throughout the Bronx. We did a recent study where we looked at all of the active patients that were seen across those 18 practices over a 2-year period, which included over 200,000 patients. And we asked how many times they had been screened for social needs just once during an 18-month time period. What we actually found was that there was a lot of heterogeneity in terms of what proportion of patients were screened for social needs, ranging from upwards of 80% of active patients screened for unmet social needs down to close to 0%.

And so even though each of the clinical teams had the same tools in theory, many clinics decided to use those tools differently, either in terms of who they screened, at what frequency, or what the goal was. And so this was actually very helpful and illuminating data to our health system because it brought up the opportunity that we had in introducing a universal objective of screening every patient once a year for unmet social needs.

One thing that we did is we took that same data and we said, if all of the clinical practices had screened just half of their active patients during that time period using the same sort of social risk prevalence that we saw, how many patients with unmet social needs would we have identified? So we actually identified 10,000, but if we would've screened just half of our active patient population, there would've been an additional 19,000. So we would've identified 29,000 patients approximately with unmet social needs.

So it highlighted the opportunity that we had if we turned the target and made the target clear in terms of what were we trying to achieve. And moving forward, our institution, coming from the top, our leadership, has determined that screening every patient for unmet social needs once a year is part of standard of care at Montefiore Health System. And so that's our goal moving forward.

Dr Acholonu: Great. What does this look like at the practice level?

Dr Fiori: Yes, it's a great question. And this also we think explains some of the heterogeneity in terms of how different teams approach this issue. One thing that we noticed among one of the practices was the deliberate effort to sort of name and call out what are the key components of doing this at a practice level? One of the practices, what we refer to this as is the Community Linkage to Care Program. And it includes 6 key components that were identified using quality improvement, performance improvement framework.

So those 6 key components, which may not look too surprising to many of you, were this idea of engaging leadership at the beginning. So getting medical directors, administrative buy-in from the beginning. Identifying your provider champions. So this is a clinician in the clinic who would serve as a point individual that would help usher in these new workflows. And then this idea of developing a standardized workflow where in terms of screening, there's a clear target population. Who are we screening? When are we doing it? Who's doing it? Where's it happening? Being clear about what the referral process is when we identify patients with unmet social needs.

And then working very closely with our team of community health workers about what is their workflow for following up with patients. So this idea of it's usually not enough just to provide one-time interaction. Here are some resources for that family, but rather we found it to be more effective for that community health worker to do some follow-up: "so here are some resources today. I'm going to call you back in 2 weeks. I'm going to check on were those useful. If they weren't useful, here's some more resources."

Dr Braveman: I just wanted to ask Dr Fiori, what have been the biggest obstacles?

Dr Fiori: Yes. I think at the beginning, one of the big obstacles was that although we all feel as clinicians that these are important things to ask about, the training required to do that and the resources available within the clinical teams so that they felt that they could do it in a meaningful and responsible way so that we were not just asking questions to ask questions, that was something we had to spend a lot of time on.

And I think there isn't a lot of guidance, even coming out of the document that I referenced previously, about how frequently should we screen? Should we screen at every visit? Is that going to be too much for patients? Are patients going to get screening fatigue from that? And so thinking about some of those details, it took time.

In terms of targeted screening vs universal, targeting in a way that did not exacerbate disparities that we were only screening certain types of patients or patients that only lived in this area. And that was something we talked a lot about at the beginning and something that we wanted to avoid.

Dr Acholonu: Fantastic. I think a few other areas that we found challenging with screening patients, Dr Fiori mentioned several of them. In addition, we would add the lack of financial incentives for providers in terms of screening. It is something that a lot of providers actually are very invested in doing, but of course it sometimes does not come with a financial incentive on the other end.

And as he already highlighted, that integration into the electronic medical record can be challenging. There are still workflows that need to be figured out and worked out a little bit more, but it is something that depending on your electronic medical record (EMR), especially now with open notes and having the access for our patients to see their information and having access for our other providers to be able to see information, we really wanted to make sure that this social determinants of health (SDOH) screening gets integrated in a meaningful way into the EMR.

The other thing we wanted to highlight is the stakeholders when you are doing SDOH screening and who matters. Who are your stakeholders that you want to really think about? And of course your patients and families are very important and are critical to this entire conversation, probably your primary stakeholders.

In addition to that, it's your entire healthcare team. It's the nurse that you may have involved in the workflow. If you're at an academic medical center, that's going to include your trainees and whether or not they are involved in the process as well. In addition to that, it's going to be faculty that are your provider champions. As you already heard, they are critical to the process.

And then in addition to that, it's going to be healthcare administration. Your C-Suite, your chief medical officer, they help to guide what the organizational values are of your institution. As you heard, at Montefiore, this is coming from the top in terms of the importance of this information and organizing and obtaining this information. And so your healthcare administration is critical in this process and should be included in the conversation.

Of course, social workers, community health workers, the people that are going to help on the other end of doing the social determinants of health screening, the allocating of the resources and the services. And the last 2 that we would highlight are those community-based organizations. We are sending them out to resources and therefore we need to partner with our community-based organizations as well as with local government officials. We are fortunate here in Montefiore to have a senior vice president for community affairs that is very actively engaged in helping us with these community-based organizations. Providing linkage programs and having that connection to your community-based organizations as well as to local government officials is really important as you think about how families are going to allocate and access these resources.

We are almost towards the end of our discussion. I wanted to ask Dr Fiori and Dr Braveman, should this responsibility of social determinants of health, should that be the concern of the clinician or should that be the responsibility of the social worker? Who should take the lead on this?

Dr Fiori: I think and I hope that medicine is moving towards the team sport arena, and that doesn't take away the responsibility of the provider to ask these questions and to be knowledgeable about how social factors influence health. So in order to really take care of families and patients, we have to acknowledge and work with families to address these issues.

My experience with the families that I get to work with is that they know that our clinical teams, we're not miracle workers, that we can't solve every problem, but I think it matters that we acknowledge that these problems exist for our families that we work with.

Dr Braveman: That is such a tough question that you ask. In terms of the responsibility of the physician, a big problem there is the pressure on physicians to see too many patients in too little time. Then to add on the screening for social needs, screening and responding to it is a heavy burden. So I feel like, I mean, it's everyone's responsibility, but especially society's responsibility.

So I guess it's this dance that we do. I mean, saying it's all society's responsibility, that would mean you don't do anything where you are. I mean, it's very exciting to me to hear more about what Montefiore is doing, and there are some other places that are doing exciting things along these lines as well.

At the same time, let's not forget about the need for advocacy because even if a very small percentage of you who are participating in this webinar have a taste for advocacy, it could make a big difference.

Dr Acholonu: Great. Thank you so much to both of you. Those are fantastic answers to what, like you said, Dr Braveman, is a tough question. In summary, we hope that we have demonstrated that health equity goes far beyond what we as healthcare providers provide to treat disease. We must also focus on the social needs of our patients if we truly want to have an impact on health. Screening for social determinants of health requires a multidisciplinary team and will likely require an iterative process with frequent involvement and engagement of our stakeholders.

And although we've only shared the process of a single institution, we do recognize that other institutions likely have similar opportunities and challenges, and we welcome the conversation to better explore what other institutions are experiencing. Implementing social determinants of health screening in a similar way as universal precautions, in other words, screen everyone, will truly strengthen our goals of providing equitable healthcare for all.

We thank you very much for participating in this activity.

This is a verbatim transcript and has not been copyedited.